The association between intellectual disability and offending is complex. Recent evidence would suggest that the received wisdom of intellectually disabled persons being more prone to offending is either incorrect or only tells part of the story. Those within the ‘borderline’ intellectual disability range may be more prone to committing sexual and criminal damage offences but those with an IQ less than 50 rarely offend.

The offender with intellectual disability shares characteristics with his counterpart from the general population. As with the general population as a whole, offending in this group is often unreported and its recognition is complicated by issues of competence. The lack of validated forensic assessment schedules for this population poses a further challenge. Some general approaches to assessment in this population are discussed. This case report illustrates the difficulties of assessing and managing offending behaviour in an individual with moderate intellectual disability. The challenge of treating offenders with an intellectual disability is immense and requires specialist expertise. Managing such cases in a generic setting is inappropriate and the need for a forensic learning disability service in Ireland is highlighted.

Open almost any recent social work magazine, or child protection text, and some reference to the abuse of disabled children will be included. Yet awareness of abuse within this group has resulted from a relatively recent growth of interest on the part of psychologists and social work and child protection professionals. Previously, sociocultural and political factors contributed to an otherwise muted response to research dating back to the 1960s, which clearly documents abuse of children who have an impairment or “developmental disability” of some kind. Reviewing this research reveals as much about society's reaction to disability and to disabled children, as it does about the abuse itself. This Annotation presents research in relation to three issues: (1) prevalence of abuse of disabled children; (2) responding to abuse; and (3) preventing abuse.

The study aimed to investigate a group of children with severe learning disabilities, challenging daytime behaviour, and severe sleep problems to see if successful behavioural treatment of the children's sleep problems resulted in reduced daytime challenging behaviour as reported by mothers and teachers.

A randomised controlled trial of behavioural interventions for the children's sleep problems was conducted (N=30). The intervention group received an individually tailored behavioural programme and were supported by telephone calls from the therapist. Baseline assessments of the children's behaviour were made using the Aberrant Behavior Checklist and were repeated 1 month and 3 months after the start of intervention.

There were no behavioural changes that were specific to children in the treatment group. However, improvements in some behaviours were seen in both the intervention and the control group at the 1-month and 3-month assessments and there was agreement between mothers' and teachers' reports for many of these changes.

The results suggest that nonspecific effects of participating in the study (including an increased sleep duration, which was seen in both groups), rather than resolution of sleep problem per se, may have a beneficial effect on child behaviour and these factors need to be identified for therapeutic use.

This study employed the self-understanding interview of Damon and Hart (1988) to assess the self-concepts of two groups of children and adolescents: a group of individuals with autism and a group of nonautistic mentally retarded individuals who were matched for age and for verbal ability. On the basis of an hypothesis concerning the interpersonal origins of social and psychological self-concepts (Hobson, 1990; Neisser, 1988), it was predicted that the participants with autism would show a relative dearth of such concepts in their talk about themselves. In accordance with our predictions, there was a significant group difference in the number and quality of statements that fell into the social category of self-concept; contrary to our predictions, however, there was no group difference in the number of statements that fell into the psychological category. In addition, although there were not significant group differences in the overall production of verbally expressed concepts concerning self-attributes of a physical, active, or psychological kind, even within these categories individuals with autism made fewer references to social interactions or qualities. These results are discussed with regard to theories of self-concept development in typically developing as well as autistic and mentally retarded individuals, and with reference to the limitations of interpersonal understanding (“theory of mind”) in people with autism.

The developmental approach to childhood psychopathology identifies deviations from typical patterns of development and stability of individual characteristics over time, and precursors in early life of later functions. The application of this approach to the social, communicative, and cognitive development of children with autism is discussed. Results from a longitudinal study of children with autism and other developmental disorders are described, indicating that children with autism have stable deficits in joint attention, representational play, and responsiveness to the emotions of others, and that early variations in these abilities are important for concurrent and subsequent language development and for peer engagement many years later.

Spontaneous shifts of attention were observed in autistic, typically developing, and nonautistic developmentally delayed infants. Three types of attention shifting behaviour were observed; (1) between an object and another object, (2) between an object and a person, and (3) between a person and another person. The two control groups shifted attention more frequently between an object and a person than between an object and another object or between a person and another person. The infants with autism showed a different pattern, shifting attention between an object and another object more than any other type of shift. Furthermore, infants with autism showed fewer shifts of attention between an object and a person, and between person and person, than did the two control groups. They also spent less time overall looking at people and looked more briefly at people and for longer durations at objects, compared to the two control groups. These results indicate an abnormality in social orientation in autism even at the early age of 20 months.

Severe retardation in a child surely has an effect on all family members. Studies of nondisabled siblings in these families have indicated both emotional risks and perceived benefits. Little is known about how out-of-home placement of the child with retardation affects the siblings. Adolescent siblings of children with retardation living at home (N=25) or in residential placement (N=20) were contrasted with siblings of children without retardation (N=28), on measures obtained from their mothers and themselves. Despite their different situations, these siblings were highly similar on measures of psychological adjustment, self-esteem, and family environment. Sibling relationships, however, were less intense, with less warmth but also lower conflict, in families where the child lived out of the home. Most siblings of children with retardation reported positive personal growth experiences while also expressing realistic concerns about the future. Siblings of children with retardation had beliefs and attitudes about placement that were highly consistent with the child's current living situation.

Objective: The repeated, self-inflicted, non-accidental injury known as Self Injurious Behaviour (SIB) is a cause of severe stress to carers and a challenge to multi-disciplinary teams working with people with a mental handicap. A need for Irish data on this problem was answered by collecting a representative cohort and following its members up to record the prevalence of SIB.

Method: The group studied included all people with an IQ of less than 50 (that is those in the moderate, profound and severe range of intellectual ability) whose place of origin was within the geographical borders of a single community care area. Following a preliminary tracing process, each person was followed up for one calendar month using a specifically prepared format to record daily occurrence of SIB.

Results: The group resulting from the tracing process consisted of 429 people (= 0.4% of the total population), 62 (=14 %) of this group exhibited SIB, during the time of the study. Of the demographic variables studied SIB was found to be related to IQ. Of those who self-injured those who showed multiple topographies and those who showed the greatest frequency of SIB were more likely to be found in the population who lived in a residential facility.

Conclusions: SIB is related to IQ but in a non-linear way suggesting that factors other than IQ militate against more severely handicapped people displaying this behaviour. SIB is not caused by living in a residential centre however our results suggest that living in a residential facility is the result of displaying SIB. This study suggests that implications for future treatment approaches and service provision for those exhibiting SIB in Ireland can be made with reference to research from other countries.

Objectives: To examine the process and outcome of use of clozapine in patients with mental handicap, with particular reference to selection of patients, response to treatment, adverse effects and withdrawal from treatment.

Methods: The case notes and medication charts of all patients commenced on clozapine between January 1991 and December 1994 were examined.

Results: Seventeen patients had been commenced on clozapine, the majority in the mild and moderate range of handicap. Fifteen had ICD-9 diagnosis of schizophrenia and all were refractory to conventional neuroleptics. Improvement was marked in 47% and substantial in 76%, with a mean daily dose of 453.8(sd = 238.5)mg and a range of 200mg-900mg. Reduction of aggressive behaviour was an important indicator of improvement. Five patients were withdrawn but only one related to side effects. Four patients had a past history of epilepsy and six others either developed seizures or EEG changes on treatment.

Conclusion: Clozapine use has been associated with considerable benefit in patients with mild and moderate handicap wh o have schizophrenia. In this population aggression responded well but a high prevalence of drug-induced epilepsy was evident.

Objective: The authors were aware of a high level of aggression in their centre and felt that a systematic review of incidents of aggression could be of benefit to both staff and residents. Method: A retrospective review of all incidents over a one year period was performed. Data involving the resident and the incident itself were analysed. An ICD 9 psychiatric diagnosis was attributed to each resident where possible. Results: The results show a large number of incidents, mostly of a minor nature. In almost half the incidents the nurse was the victim. There was a lower number of incidents in January and February. Forty one of the 45 residents involved in incidents had a psychiatric diagnosis. Conclusion: There is a general trend for moving from residential settings to the community. Our results suggest that as time goes on our centre will contain more residents with a psychiatric diagnosis who have a potential for aggression. We suggest ways of coping with this aggression and produce an incident form for recording aggressive incidents.

Objective: To study the relationship between epilepsy and aggression in a population of severely mentally handicapped people. Methods: Comparing epilepsy and aggression variables in people with epilepsy without aggression, people with aggression without epilepsy, and people with both. The epilepsy variables were: seizure frequency, classification, anticonvulsant drugs, therapeutic drug monitoring, and neuroleptic drugs. Aggression variables were: frequency, direction, type, and neuroleptic drugs. Results: Prevalence of aggressive behaviour was similar in people with and without epilepsy (36%). Partial seizures were less prevalent in people with epilepsy and aggression. People with epilepsy were more likely to manifest unprovoked aggression directed against property. Conclusion: Some episodes of aggressive behaviour in people with epilepsy may be ictal in origin.

Objective: To investigate the relationship between behavioural disturbance and psychiatric diagnosis in male mentally handicapped adults resident in a long stay unit. Method: The case notes of all 144 residents of St. Raphaels were reviewed. Diagnoses were classified according to the International Classification of Diseases Ninth Revision (ICD-9) and grouped into one of four categories Infantile Autism, Functional Psychoses, Personality/Behavioural Disorder and Emotional Disorders. Carers (Senior Nursing Staff) were interviewed using the Adaptive Behaviour Scale Part 2 (ABS Part 2) as a measure of behavioural disturbance in the preceding year for the 144 residents. Results: 56% of residents had significant psychiatric disorder. Those with a psychiatric diagnosis showed increased behavioural disturbance across a wide range of measures (p<0.001) with Hyperactivity, Self Abuse and Violence showing greatest discriminative power. However there was not a relationship between diagnostic category and pattern of scoring on the ABS Part 2. There was a significant relationship between Degree of Mental Handicap and Psychiatric Diagnostic Category (p<0.001). Neither psychiatric morbidity nor behavioural disturbance was associated with epilepsy, age or duration of stay. Conclusions: Mentally handicapped adults in residential care show high rates of psychiatric disturbance. Those with psychiatric diagnoses exhibit a wide range of disturbed behaviours but similar patterns of maladaptive behaviour occur across the spectrum of psychiatric disorders. These findings refer to a male residential population and cannot be generalised to all mentally handicapped.

Objective: This study investigated the frequency of abnormal Dexamethasone Suppression Test (DST) in a randomly selected group of mentally handicapped subjects. Method: Forty three subjects living in the community were selected and assessed on a variety of clinical rating scales including Hamilton Rating Scale for Depression (HDS) and Wessex Case Register Form (WCRF). DST was conducted on all the patients and the findings correlated with demographic and clinical variables. Groups defined by DST status were also compared using t-test. In subjects who showed an abnormal response, clinical assessments and DST was repeated after 3 months. Results: Only 7 of 43 subjects showed an abnormal response which did not correlate with either the severity of affective symptoms or the presence or absence of behavioural difficulties. Six of the 7 DST positive subjects were either severely or profoundly impaired on DSM-III criteria indicating that the underlying brain pathology may be pathogenetically important. This was supported by the observation that abnormal DST response was enduring at follow up. Conclusions: The findings suggest that DST may be of little value as a diagnostic tool in the mentally handicapped.

This paper explores the contribution of psychoanalytic theories to mental handicap and proposes that mental handicap can be seen primarily as a problem of communication with others (discourse), with oneself (thinking) and with one's own past (history).

This paper also examines concepts of curiosity and thinking, knowledge of history and mental handicap as discourse. To illustrate certain points, examples from case histories are used (real names not used).

This study examines the changes in behaviour following residential relocation in 2 groups of adults with mental handicap. Both groups were transferred (one from the community and one from psychiatric hospitals) to small bungalow dwellings in a village type setting at a centre for persons with mental handicap. Relocation had a major impact on a number of behaviours, most prominently, ‘domestic activities’. The impact of the transfer on both groups, the relevance of the findings for future transfer projects and suggestions for future research are discussed.

One Hundred and two sudden or traumatic deaths of mental handicap inpatients were examined retrospectively over a 28 year period. Data was obtained on each case from medical and nursing case notes and death certificates. Post-mortem results were available for half of the deaths. Cardio-vascular causes accounted for 50% of the total. Sudden deaths of profoundly handicapped patients occurred at a significantly younger age than severely, moderately or mildly handicapped patients. In the latter half of the 28 year period there was an increased incidence of traumatic deaths and sudden deaths due to asphyxia. There was also a significant increase in the mean age of sudden deaths due to epilepsy. Probable explanations for these findings are discussed. In particular, recent accidental traumatic deaths may be related to the process of increased reintegration of patients into the community; a relationship between neuroleptic and anticholingeric medication and asphyxial deaths is proposed.

A study of the dietary intake of 115 male and 217 female mentally handicapped persons aged 15–64 years in five long-stay institutions was carried out using a semi-weighed technique over 4 d. Nineteen per cent of males and 5% of females were classified as being underweight and 15% of males and 27% of females were classified as being obese. The average daily intakes of nutrients were: energy 8.8 MJ, protein 92 g, carbohydrate 218 g, fat 101 g, dietary fibre 18 g, calcium 1024 mg, iron 12.5 mg, vitamin B6 1.4 mg, vitamin B12 10.8 μg, ascorbic acid 68 mg. The distribution of energy between protein, carbohydrate and fat was 18, 39 and 43% respectively. Energy intakes were not related to ambulatory status, degree of mental handicap, the level of drug usage or body mass index. Energy intakes varied significantly between hospitals and between the sexes.

Thirty two trainees with mental handicap were resettled from two psychiatric hospitals into a centre for people with mental handicap. The progress and problems encountered are described. Recommendations are made for future resettlement programmes.